Pain Management in

Children

Definition of Pain
As defined by the International
Association for the Study of Pain
(IASP), pain is "an unpleasant
sensory and emotional experience
associated with actual or potential
damage, or described in terms of
such damage."

Categories of Pain
associated with a disease state (eg, arthritis,
sickle-cell disease)
associated with an observable physical injury
or trauma (eg, burns, fractures)
not associated with a well-defined or specific
disease state or physical injury (eg, tension
headaches, recurrent abdominal pain)
associated with medical and dental
procedures (eg, circumcisions, injections).

Physiology of Pain
Nocioception is a physiologic
mechanism of noxious stimulus
transduction
Requires a nocioceptor
Not necessarily the same as pain
Biologic role is protective

Nocioceptors
Nocioceptors are free nerve endings
Ubiquitous distribution
Chemically activated in response to
tissue damage
Inotropic/matabotropic
Nocioceptors can be sensitized
Primary hyperalgesia
Secondary hyperalgesia

Nocioceptors
Free nerve endings
High threshold
Slow pain
C fibers, unmyelinated, slow burning aching pain,
Substance P
Fast pain
A delta fibers, myelinated, sharp prickly pain,
glutaminergic
A delta fibers project to projection neurons in laminas I
and V
C fibers project to projection neurons in lamina II
Both also project to inhibitory and excitatory interneurons

Modulation of Pain
Information
Gate Control Theory
Nocioception arises from activation of
nocioceptors
Pain sensation is a product of several
interacting neural systems
Afferent transmission relies on a balance in
the activity of both the pain fibers and large
proprioceptive/mechanosensory fibers
Inhibitory interneurons are spontaneously
active and inhibit projection neurons

Dorsal Horn Synapses

Neurotransmitters
Glutamate
Substance P
CGRP
CCK
Opiates

Receptors
NMDA
Neurokinin-1
?
?
Endorphin (mu,
kappa, sigma)

Supraspinal Pain
Modulation
Pain transmission can also be
modulated by descending
pathways
The analgesia system

Analgesia System
Periaqueductal gray and
periventricular areas (enkephalin)
Raphae magnus nucleus (serotonin)
Dorsal horn interneurons
(enkephalin)
A and C fiber Inhibition (pre- and
post-synaptic)

Advances, but.
Misconception that neonates,
infants, and children do not feel or
react to pain in the same way as
adults.
Fears of opioid addiction and
adverse effects
RESULT: ineffective pain treatment
for most pediatric patients

Postsurgical Stress
Response
Metabolic, hormonal, and hemodynamic
response to major injury or surgery
Neuroendocrine cascade with release of
catecholamines, adrenocortical hormones,
glucagon, and other catabolic hormones
Results in increased oxygen consumption,
increased carbon dioxide production,
hyperglycemia, and generalized catabolic
state with negative nitrogen balance

Occurs even in preterm infants and the

magnitude of the response correlates
with mortality
An inquiring, analytical mind; an
unquenchable thirst for new knowledge;
and a heartfelt compassion for the ailing
- these are prominent traits among the
committed clinicians who have
preserved the passion for medicine.

Principles
Unrelieved pain has negative physical and psychological
consequences
Prevention is better than treatment
Successful assessment and control of pain depends partly
on a positive relationship between the health care
professionals and the children and their families.
Children often cannot or will not report pain to their health
care providers
Routine assessment increases the health care professionals
knowledge of the child which, in turn, optimizes the
assessment of pain and its subsequent management
Techniques are now available that make pain reduction to
acceptable levels a realistic goal in the majority of
circumstances

Factors that Modify

Pain Perceptions
Age
Cognition
Gender
Previous pain experience
Temperament
Cultural and family factors
Situational factors

Personalizing the
Approach
Tailor assessment strategies to the childs
developmental level and personality style and to the
situation
Obtain a pain history from the child and/or the parents.
Learn what word that child uses for pain (hurt, boo-boo,
owie)
Elicit from the family culturally determined beliefs about
pain and medical care
Measure the childs pain using self-report and/or
behavioral observation tools.

Infants
There is not easy or scientific way to
tell how much pain an infant is having
Not crying
Moaning or quietly crying
Gently crying or whimpering
Stop crying when picked up and
comforted
Not stop crying when picked up and
comforted

Toddlers
May become very quiet and
inactive while in pain or may
become very active
May use only one word (owie,
booboo)
Parents report that they arent
acting like they normally do

Behavioral
Observations
Use behavioral observation with
preverbal and nonverbal children
Vocalizations
Verbalizations
Facial expressions
Motor responses
Body posture
Activity
Appearance

FACE

LEGS
ACTIVITY

CRY

CONSOLE

No particular expression or smile

Occasional grimace or frown, withdrawn,

disinterested

Frequent to constant quivering chin, clenched

Normal
position or relaxed
jaw
Uneasy, restless, tense

2
0

Kicking or legs drawn up

Lying quietly, normal position, moves easily

Squirming, shifting back and forth, tense

Arched, rigid or jerking

No cry, (awake or asleep)

Moans or whimpers; occasional complaint

Crying steadily, screams or sobs. Difficult to

console.
Content, relaxed

Reassured by occasional touching, hugging or

being talked to.

Difficult to console or comfort

F
L
A
C

Behavioral
Observations
Interpret behaviors cautiously
Use parents report of pain when the
child is unwilling or unable to give a selfreport
Use physiologic measures (eg. Heart
rate and blood pressure) only as
adjuncts to self-report and behavioral
observation (neither sensitive nor
specific as indicators of pain)

School-age and Older

Can often tell you more about

pain using units of measure (0 is
no pain and 5 is bad pain)
Can color on body outlines where
they hurt and show parents and
health care providers where they
hurt

Pain Assessment Tools

Poker chip
:
Word-graphic rating scale

Adolescents
Can explain pain more clearly
because they understand words
and concepts that younger
children dont
They can use specific words to
describe the character of the pain

Procedure-related Pain
Provide adequate preparation of
the child and family
Be attentive to environmental
comfort (If possible, do not perform
the procedure in the patients
room)
Allow parents to be with the child

Procedure-related Pain
Combine pharmacologic and
nonpharmacologic options when
possible and appropriate

Pharmacologic
Analgesics and/or local anesthetics
Systemic analgesics
Anxiolytics or sedatives
Barbiturates and benzodiazepines
produce anxiolysis and sedation but
not analgesia

NSAIDs
Significant opioid dose-sparing
effects
Must be used with care in patients
with thrombocytopenia or
coagulopathies

Acetaminophen
Acetaminophens mechanism of action involves inhibition
of central cyclo-oxygenase
Additional mechanisms of action have also been suggested
for acetaminophen, including inhibition of nitric oxide
formation that results from activation of substance P and
N-methyl-D-aspartate (NMDA) receptor stimulation.
Available in various formulations, including drops, liquid,
tablets, caplets, sustained-release tablets and
suppositories.
When dosing acetaminophen for pediatric use, consider its
concentration in other medications that the patient may be
taking, including weak opioids and over-the-counter flu,
sinus or allergy medications

Opioids
Cornerstone of management of
moderate to severe acute pain
Tolerance and physiologic
dependence are unusual in short-term
postoperative opiate-nave patients
Psychologic dependence and
addiction are extremely unlikely to
develop after the use of opioids for
acute pain

Opioids and
Dependence
There is no known aspect of
childhood development or
physiology that indicates any
increased risk of physiologic or
psychologic dependence from the
brief use of opioids for acute pain
management

Morphine
Morphine is the standard for opioid
therapy
If morphine cannot be used
because of an unusual reaction or
allergy, another opioid such as
hydromorphone can be substituted

Meperidine
Should be reserved for very brief courses in
patients
Contraindicated in patients with impaired renal
function or those receiving antidepressants of
the monoamine oxidase inhibitor
classNormeperidine is a toxic metabolite of
meperidine and is excreted through the kidney
Normeperidine is a cerebral irritant
accumulation can cause effects ranging from
dysphoria and irritable mood to seizures in
otherwise healthy people

Dosing Opioids
Titrate the opioid dose and interval to increase the amount
of analgesia and reduce the side effects when necessary
Children vary greatly in their analgesic dose requirements
and responses to opioid analgesics, and the recommended
starting doses may be inadequate
Use relative potency estimates to select the appropriate
starting dose, to change the route of administration, or to
change from one opioid to another
Provide opiates around the clock or by continuous infusion
rather than as neededOffer rescue doses for breakthrough
or poorly controlled pain
Use patient-controlled analgesia for developmentally
normal children 7 years and older

Administration of
Opioids
Administer opioids through
intravenous catheter or orally
Use intramuscular injections only
under exceptional circumstances

Alternative Routes of
Administration
Regional anesthesia

Neonates and Infants

Particularly susceptible to apnea
and respiratory depression
Appears to be dose-related
However, neonates and infants DO
experience pain, and adequate
analgesia is ESSENTIAL

Pain Assessments Pharmacologic

What are the childs and parents previous
experience with pain?
Is the child being adequately assessed?
Are analgesics ordered for the prevention
or treatment of pain?
Is the analgesic dosage appropriate for the
pain being experienced or expected?
Is the timing of administration appropriate
for the pain being experienced or
expected?

Pain Assessments Pharmacologic

Is the route of administration appropriate
for the child?
Is the child adequately monitored for the
occurrence of side effects?
Are the side effects appropriately
managed?
Has the analgesic regimen provided
adequate comfort from the childs or
parents perspective?

Nonpharmacologic
Sensorimotor strategies for infants
Cognitive/behavioral strategies for
older children
Child participation strategies
Physical strategies

Distraction
Blowing bubbles
Playing with pop-up toys
Looking through a kaleidoscope
Imagining a superhero

Suggestion
Magic glove technique
Basic principles
Willingness to be involved
Trust in the coach
Ability to participate

Breathing Techniques
Rhythmic, deep-chest breathing
Patterned, shallow breathing

Guided Imagery
A form of relaxed, focused
concentration
Favorite place, favorite activity
Not only produce distraction, but
also enhance relaxation

Progressive Muscle
Relaxation
Recognize and reduce body
tension associated with pain
Decrease anxiety and discomfort

Biofeedback
Uses instruments to detect and
amplify specific physical states in
the body and help bring them
under ones voluntary control
Mechanism of pain relief is based
on specific physiologic changes
caused by the biofeedback

Hypnosis
Altered state of consciousness is
used
Concentration is focused,
narrowed, absorbed

Transcutaneous
Electric Nerve
Stimulation
Involves stimulation pulses
produced by a battery operated
unit delivered to skin electrodes
surrounding the area where the
pain is occurring

Acupuncture
Based on a theory that energy
(Chi) flows through the body along
channels (meridians) which are
connected by acupuncture points
Pain results when flow of energy is
obstructed
Acupuncture restores that flow and
eliminates or reduces pain

Headache
Biofeedback and Relaxation in the Management of
Pediatric Headache
Summary and interpretation of controlled studies
supports behavioral approach as a potent
alternative
Review of research on behavioral treatments for
recurrent headaches
Relaxation and self-hypnosis is a well-established
and efficacious treatment for recurrent headaches

Vaccine-related Pain
Attitude, empathy, instruction
Distraction, hypnosis
Sugar nipples
Topical anesthetics (EMLA)
56 references

Fracture Reduction
Hypnosis used to diminish pain and
anxiety in patients with angulated
forearm fractures (no other form of
sedation or analgesia available)

Postoperative Pain
Emotional support, helping with
activities, creating a comfortable
environment used routinely
Other nonpharmacologic measures
used less frequently
Related to background of the
nurses

Recurrent Abdominal
Pain
Fiber, Fiber-biofeedback, Fiberbiofeedback-cognitive/behavioral
intervention, Fiber-biofeedbackcognitive/behavioral interventionparental support
All groups showed improvement, but
treatment group showed more
improvement

Rheumatic Illnesses
Massage helpful for JRA marked
decrease in subjective pain,
observed pain, and tender trigger
points

Pain Assessments
-Nonpharmacologic
What are the childs and parents
experiences with and preference for the
use of the strategy?
Is the strategy appropriate for the childs
developmental level, condition, and type
of pain?
Is the timing of the strategy sufficient to
optimize its effects?
Is the strategy effective in preventing or
alleviating the childs pain?

Pain Assessments
Nonpharmacologic
Are the child and parent satisfied
with the strategy for prevention or
relief of pain?
Are the treatable sources of
emotional distress for the child
being addressed?

AAP Recommendations
Expand knowledge about pediatric
pain
Provide a calm environment for
procedures
Use appropriate pain assessment
tools and techniques
Anticipate predictable painful
experiences, intervene, and monitor

AAP Recommendations
Use a multimodal approach to pain
management
Involve families, tailor interventions to
individual child
Advocate for child-specific research in
pain management
Advocate for effective use of pain
medication in children to ensure
compassionate, competent management
of their pain

Therapeutic Alliance
Pain is managed within a
therapeutic alliance among the
child, his or her parent, nurses,
physicians, and other health care
professionals